This paper argues that Canadians are at a crossroads in terms of the future of medicare.Critical directional decisions will be made at the First Ministers Meeting in a few months.Ottawa must decide its role before it negotiates with the provinces the future of a policy that is an integral part of the country’s identity.

One option is to continue with a dysfunctional status quo.A second option is a withdrawal by Ottawa from medicare through final, permanent tax transfer.The third option is for the federal government to once again become a real partner by working with the provinces to reshape the national dimensions of medicare and by sharing the fiscal risk of health care costs with the provinces.This last option should focus on the transformation of the health care system, with Ottawa supporting the provinces in the difficult task of improving access, quality and outcomes in as cost-effective manner as possible.

Now a professor of public administration at the University of Regina, Gregory Marchildon was a key player in federal-provincial negotiations over medicare and Executive Director of the Romanow Commission.